MOAA has recently heard from TRICARE Prime families who are surprised their medical care is being transitioned to military treatment facilities (MTFs) and seeking options to remain with civilian health care providers.

MOAA has advocated for improved access to care, including greater flexibility in TRICARE plan enrollment. As TRICARE’s open season approaches and the military health system (MHS) stabilization strategy moves ahead, it is important for beneficiaries to understand what it means to enroll in TRICARE Prime so they can choose the TRICARE plan that best meets their needs.

TRICARE open season does not apply to TRICARE For Life, but the federal benefits open season provides an opportunity for Medicare-eligible beneficiaries to enroll in dental and vision coverage through the Federal Employees Dental and Vision Insurance Program (FEDVIP). This year, federal benefits open season runs Nov. 11 to Dec. 9.

When you live near an MTF and enroll in TRICARE Prime, you are choosing to use the MTF for your care if the military hospital or clinic has the capacity and capability to treat you. TRICARE Prime patients generally will receive care from TRICARE network providers only if nearby MTFs can’t provide the necessary care within access standards.

The size and scope of military hospitals and clinics vary greatly by location, so your experience as a Prime beneficiary can vary.

• Some installations have minimal MTF capacity focused only (or primarily) on active duty servicemembers. At these locations, Prime families get almost all their care in the TRICARE network – about 26% of Prime-enrolled beneficiaries have a civilian provider as their TRICARE Prime primary care manager (PCM).
  
  
• About 68% of TRICARE Prime beneficiaries are enrolled with a PCM at an MTF. Some of these families will be referred to the TRICARE network for most specialty care. Others, such as those located near large military medical centers such as Naval Hospital San Diego or Brooke Army Medical Center in San Antonio, may get almost all their medical care from MTFs, including specialty care.

Capacity at MTFs can change across time. For the past several years, many military families were shifted to the TRICARE network, but the new MHS stabilization strategy aims to bring 7% of beneficiary care back into MTFs from the TRICARE network.

MOAA understands most of this shift will occur in areas near large military medical centers, although we have heard reports about families located near smaller military hospitals being recalled to MTFs for primary care.

Managing Your Coverage

TRICARE open season runs Nov. 11 to Dec. 10. Open season lets you change your TRICARE plan for next year. Changes you make during this time start Jan. 1, 2025. 

TRICARE Prime is managed care that requires a PCM referral for most specialty care. Beneficiaries who live near an MTF may be required to receive their care at the military hospital or clinic. Prime offers lower out-of-pocket costs, particularly for active duty families who have no cost sharing for covered services if they follow Prime referral and authorization policies, but it is more restrictive in terms of provider choice.

[RELATED: TRICARE Cost Comparison Tool]

TRICARE Select requires families to pay a deductible and copays/cost shares with a maximum out of pocket from $1,000 to $1,300 annually for active duty families. Select allows greater provider choice, including the option to see civilian medical providers.

Access to care improvements, including greater flexibility in TRICARE plan enrollment, will continue to be a top priority for MOAA in the 119th Congress.